MIF is the first identified T-cell-derived soluble lymphokine. MIF was first described as a soluble factor with the ability to modify the migration of macrophages (1). The molecule responsible for the biological actions ascribed to MIF was identified and cloned in 1989 (2). Initially found to activate macrophages at inflammatory sites, it has been shown to possess pluripotential actions in the immune system. MIF has been shown to be expressed in human diseases which include inflammation, injury, ischaemia or malignancy. MIF also has a unique relationship with glucocorticoids by overriding their anti-inflammatory effects.
Recent studies have indicated that monoclonal antibody antagonism of MIF may be useful in the treatment of sepsis, certain types of cancers and delayed type hypersensitivity. Antibody antagonism of MIF has also been shown to have activity in adjuvant- or collagen-induced arthritis animal models and other models of inflammatory and immune diseases.
Although antibody antagonism of MIF is one potential way to provide therapeutic treatments, such biological molecules can be expensive to prepare on a commercial basis and further, can be limited in the way they are administered (generally by injection) and do not readily lend themselves to formulations for administration by other means eg oral administration.
Small molecule inhibitors may overcome one or more such difficulties connected with the use of biological therapeutic treatments. There exists a need, therefore, for small molecule inhibitors of the cytokine or biological activity of MIF. Small molecule inhibitors of the MIF would have therapeutic effects in a broad range of diseases, whether given alone or in combination with other therapies.
Examples of agents which could be used in combination with a compound of formula (I) include glucocorticoids, antirheumatic drugs, immunosuppressive drugs, anti-cytokine therapies, antagonists or inhibitors of nitrogen-activated protein (MAP) kinases, antagonists or inhibitors of nuclear factor kappa-B (NF-κB) signal transduction pathway, antibodies, protein therapeutics or small molecule therapeutics interacting with adhesion molecules and co-stimulatory molecules, bronchodilators, antagonists of eicosanoid synthesis pathways, agents used for the treatment of inflammatory bowel disease, anti-cancer drugs, antisense oligonucleotides, interfering RNA and ribozymes.
For example, glucocorticoids have been used to treat human diseases for over fifty years and are effective in a range of diseases which include inflammation, injury, ischaemia or malignancy. Although debate continues in relation to their impact on disease prognosis, their influence on symptoms and signs of inflammation, especially in the short term, can be dramatic.
Despite their benefits and efficacy, the use of glucocorticoids is limited by universal, predictable, dose-dependent toxicity. Mimicking Cushing's disease, a disease wherein the adrenal glands produce excess endogenous glucocorticoids, glucocorticoid treatment is associated with side effects including immunosuppression (resulting in increased susceptibility to infections), weight gain, change in body habitus, hypertension, oedema, diabetes mellitus, cataracts, osteoporosis, poor wound healing, thinning of the skin, vascular fragility, hirsutism and other features of masculinization (in females). In children, growth retardation is also noted. These side effects are known as Cushingoid side effects.
Since the side effects of glucocorticoids are dose dependent, attempts to reduce the dosage requirement have been investigated, including combination therapies in which glucocorticoids are administered with other therapeutic agents. These combination therapies are sometimes referred to as “steroid-sparing” therapies. However, currently available combination therapies are non-specific as the other therapeutic agents do not address biological events which inhibit the effectiveness of glucocorticoids. Such combination therapies are also typically associated with serious side effects.
Furthermore, glucocorticoids are incompletely effective in a number of disease settings, leading to the concept of “steroid-resistant” diseases. Agents which amplify or enhance the effects of glucocorticoids would not only allow the reduction of dose of these agents but may also potentially render “steroid-resistant” diseases steroid-sensitive.
There is a need for effective therapies which enable a reduction in the dosage level of glucocorticoids. There is also a need for effective treatment of “steroid-resistant” diseases. Preferably, such therapies or treatments would address factors which directly limit the effectiveness of glucocorticoids.
Therapeutic antagonism of MIF may provide “steroid-sparing” effects or be therapeutic in “steroid-resistant” diseases. Unlike other pro-inflammatory molecules, such as cytokines, the expression and/or release of MIF can be induced by glucocorticoids (3), (4). Moreover, MIF is able to directly antagonize the effects of glucocorticoids. This has been shown to be the case for macrophage TNF, IL-1β, IL-6 and IL-8 secretion (5), (6), and for T cell proliferation and IL-2 release (7). In vivo, MIF exerts a powerful glucocorticoid-antagonist effect in models including endotoxic shock and experimental arthritis (5), (8). In the context of an inflammatory or other disease treated with glucocorticoids, then, MIF is expressed but exerts an effect which prevents the glucocorticoid inhibition of inflammation. It can therefore be proposed that therapeutic antagonism of MIF would remove MIF's role in inhibiting the anti-inflammatory effect of glucocorticoids, thereby allowing glucocorticoids to prevail. This would be the first example of true “steroid-sparing” therapy. In support of this hypothesis is the observation that anti-MIF antibody therapy reverses the effect of adrenalectomy in rat adjuvant arthritis (9). By neutralizing the natural glucocorticoid ‘counter-regulator’ effect of MIF, it is envisioned that with MIF antagonism, steroid dosages could be reduced or even eliminated in inflammatory disease, particularly in those diseases that are associated with the glucocorticoid resistance (10), (11). There is a need, therefore, for therapeutic antagonists of the cytokine or biological activity of MIF.